CSR of hospitals: A few free heart surgeries and some mobile clinics. What else?

It would not be incorrect to state that healthcare and social responsibility go hand in hand. After all, few things are as important, essential and literally a matter of life and death as right and timely healthcare. The morally hazardous bit comes in when the term ‘corporate’ is inserted before social responsibility. Health is such an indispensable and crucial part of every human’s existence that when it is used to rake in profits, the implications are huge and more often than not, tinged with plenty of greys and blacks. While universal healthcare remains a dream in this country (at least we have the excuse of being a developing country, unlike the United States), for-profit healthcare companies have mushroomed. For example, the health insurance industry is already at over $0.7 billion in terms of gross direct premiums and is growing rapidly.

The state of Indian health
While the Indian healthcare industry had a market value of $81.3 billion in 2014 (the hospitals sector contributes nearly 70 per cent to this), it is expected to touch $160 billion by 2017. The private hospitals segment is estimated to reach $125 billion by the same year, according to one study by ASSOCHAM. More interestingly, over 72 per cent of rural and 79 per cent of urban population rely on private hospitals for treatment, and this pretty much sums up the state of our public healthcare system. Over the past decade, healthcare has seen increasing corporatisation with the largest hospital chains accounting for more than 200 hospitals and adding 70 per cent of the country’s hospital beds. This isn’t surprising, though, since the expenditure on public healthcare has decreased – from 4.3 per cent a decade back to 4.05 per cent – as a percentage of budget. There has been a marked decline in the use of public facilities as well – between 1987 and 1996, this had already gone down by 30 per cent. India’s investment in public health remains around one per cent of its GDP, making it one of the lowest in the world. In fact, out-of-pocket expenditure on healthcare is twice the levels of public spending, a dubious distinction for this country. Like in education, state intervention in healthcare seems to find no takers in an increasingly neoliberal world order.

This should be a cause for concern for everyone – healthcare is a public good and necessity. The government washing its hands of delivering this essential service and outsourcing it to the market hasn’t worked in other countries and is unlikely to work in a country as poor as India. Take a look at any developed country with a well-functioning healthcare system and one fact immediately stands out – the large proportion of public financing accorded to it.

As per the health ministry, the doctor-to-patient ratio for rural India is 1:30,000, way below the WHO’s recommended 1:1,000. The hospital bed penetration is at 1.3 per 1,000 people against the global median of 2.5. And this is before one gets into the abysmal number of qualified physicians and nurses. Already the country needs over 1.5 million additional doctors and 2.4 million nurses to meet the rapidly growing demand. All of this has coincided with the rise in healthcare costs and an increasing reliance on private services. Between 2004 and 2014, the average expenditure per hospitalisation increased by about 176 per cent for urban patients and over 160 per cent for rural patients. This is especially alarming when combined with the fact that over 70 per cent of Indians have no insurance backup to ride them out and almost 60 per cent of Indians pay for their health expenditures out of pocket. Medical inflation is almost always higher than overall inflation, and these high costs disproportionately affect the poorest classes the most. Even the limited healthcare resources are unequally distributed, with urban areas accounting for 65–70 per cent of infrastructure and manpower. All of these aggravate the burning issue of high poverty in the country – 55 million Indians fell into the poverty trap because of their healthcare spending in 2011–12; out-of-pocket health expenses are responsible for nearly one-sixth of India’s poverty burden; and high costs deter the poor from seeking medical help, thereby perpetuating the never-ending cycle.

In terms of diseases, India accounts for 20 per cent of the total global number. Its share of child deaths under the age of 5 and neonatal deaths is 21 per cent and 27 per cent, respectively. Noncommunicable diseases are responsible for more than 60 per cent of deaths in the country; in 2012, there were 253 deaths per 100,000 persons due to communicable diseases, the global average being 178. The number of diabetes patients is 66 million, while 2.2 million TB cases are registered every year. It has been estimated that noncommunicable diseases, which are mainly chronic in nature, will cost the country around Rs 280 trillion between 2012 and 2030 in terms of economic output. The number of deaths attributable to chronic diseases has increased from 3.78 million in 1990 (40.4 per cent of all deaths) to a projected 7.63 million in 2020 (66.7 per cent).

The lack of a robust public healthcare system and the steep costs charged by private hospitals may have contributed to the rise of alternative medicines like Patanjali Ayurved, which produces over 300 medicines for treating a range of ailments including common cold and chronic paralysis. Of course, Indians have been known to rely on Ayurveda and locally sourced and brewed solutions since ages. But forming a new ministry like the Department of Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy (AYUSH) to develop education and research in Ayurveda, yoga, naturopathy, homeopathy, and other alternative medicines is probably taking it a bit too far. Homeopathic solutions have been roundly criticised and debunked but that doesn’t seem to have made much of a dent in its popularity and is unlikely to in the near future, at least till education and healthcare become priorities for the government.

The CSR state of private healthcare
CSR by the large private hospital entities is probably not as well known when compared to the CSR of some of their manufacturing and tech counterparts, who tend to have bigger and better publicised programmes. CSR initiatives by these hospitals can be broadly classified into four buckets: rural healthcare (which may take the form of free clinics, financial support, free surgeries, technology-based solutions, etc.), awareness campaigns, disaster-relief campaigns, and education. Even then, many don’t have clearly articulated CSR policies (as mandated by the 2013 Act) and details are sparse. Some, like Narayana Hrudayalaya, barely dedicate a page to it on their websites. While providing healthcare is a noble mission, when one is doing it as a for-profit activity, a little bit of CSR can go a long way.

Apollo Hospitals have multiple projects running parallel with the mission of providing healthcare to the underprivileged sections of society, and these cover free medical clinics (mostly in the South), cardiac care and heart surgery for children, and cancer care. Its rural initiatives include long-distance healthcare through telemedicine, services to hearing-impaired children, and its Apollo REACH hospitals, which are exclusively for rural and semi-urban areas. Awareness campaigns include the Billion Hearts Beating Foundation, set up to spread awareness about heart diseases. Aside from workshops and drives, free check-ups are conducted in old-age homes and schools catering to poor children.

Fortis takes a similar approach, providing heart surgeries, cleft-lip corrective surgeries, and epilepsy surgeries to children and medical support for women survivors of violent attacks. The latter initiative is quite commendable as it involves long-term support for acid-attack victims, including surgeries, mental and psychological rehabilitation, and helping them financially through other organisations. It has partnered with numerous charitable organisations to provide healthcare to poorer sections, although this seems quite limited in its current scope. Construction of toilets has been taken up under the ambit of projects like World Toilet Organization (WTO) and Care Today Fund. Health-awareness camps and disaster-relief programmes are also organised.

Max Healthcare is one of the few companies with ‘preventive healthcare’ as one of its stated CSR activities. It has also correctly identified nutrition for poor and underserved women and children as one of its key interventions. Other projects include providing medical support and surgeries to underprivileged sections and remote areas, campaigns around personal and environmental hygiene, education initiatives in selected villages, and vocational training for livelihood generation. The last one is unique among similar entities since not many hospitals choose to work with SHGs, which can be an effective intermediary if used well. Key performance indicators are also mentioned in its CSR policy document.

Wockhardt’s CSR projects are not dissimilar to Max’s. Nutrition, hygiene initiatives and free primary healthcare to rural areas are some salient features. Other initiatives include adopting of villages, education promotion, medical support to children born with heart defect, and providing safe drinking water. A more interesting initiative is Wockhardt Skills Development Institute – it trains students on healthcare courses, after which they are placed in hospitals and nursing homes. Wockhardt happens to be one of the few such organisations to publish a detailed CSR report, which provides a good understanding of its various CSR projects and impact. Other new programmes undertaken are educating the public on organ donation, a anganwadis certification project, and Swachh Bharat participation, among others.

At Narayana Hrudayalaya, four emergency medical clinics have been set up at railway stations and mobile mammography screening is conducted as part of its CSR activities. Through its Rajiv Gandhi Arogya Yojana (RAY) programme, it has established four primary healthcare clinics in Amethi, Uttar Pradesh. One of its more noteworthy efforts is its Care Companion Program, which trains and educates patient’s caregivers. Technology-based solutions and other resources to deliver affordable primary healthcare services have been designed and incorporated into its eHealth centres in semi-urban and rural areas in Karnataka, West Bengal, Tamil Nadu, Gujarat and Rajasthan. Through its Udaan initiative, deserving candidates from rural backgrounds are coached and mentored to pursue a career in medicine.

Then there are the large, multi-speciality hospitals like Kokilaben Dhirubhai Ambani Hospital with their token CSR-ism. Some health camps are organised and reduced rates for children with heart defects are offered at times. Funnily enough, donations are sought to bridge the subsidy gaps – that is a little hard to believe when you have ‘Ambani’ plastered over your name.

CB observations
One common theme that emerges after going through the CSR efforts of these large hospitals is that despite some tangible actions and well-placed intentions, few manage to provide a good assessment of the long-term impact and challenges ahead. Even worse, none of them report their sustainability performance, which is quite worrisome since hospitals consume substantial energy resources and choke up plenty of waste, much of it being toxic. Their dependence and impact on the environment is undeniable but we have little idea if any of these super-speciality chains are working to mitigate these effects. A 2009 WHO paper titled ‘Healthy Hospitals, Healthy Planet, Healthy People’ stated that “hospitals are energy- and resource-intensive enterprises that contribute substantially to climate change while inadvertently contributing to respiratory and other illnesses.” The paper identified seven environmental elements through which hospitals can rectify this: energy efficiency, green building design, alternative energy generation, transportation, food, waste, and water. It is anybody’s guess if our hospitals have bothered to implement any of these logical suggestions.

There is also little information on the protection of the interests of all stakeholders, starting from the supply chain to the nurses, administrative and low-wage workers and cleaning staff. Since it is the doctors who command all attention and the high salaries, little is known of the state of the invisible staff who are responsible for making these hospitals a functioning unit. The lack of adequate reporting isn’t limited to India, though. Many of the healthcare companies listed in Fortune 1000 have conveniently ignored issuing non-financial reports. In 2008, only seven healthcare service providers globally issued sustainability reports as per the standard Global Reporting Initiative’s (GRI) framework, one of which was a clinic service in Spain.

A 2009 WHO paper stated that “hospitals are energy- and resource-intensive enterprises that contribute substantially to climate change while inadvertently contributing to respiratory and other illnesses.” The paper identified seven environmental elements through which hospitals can rectify this: energy efficiency, green building design, alternative energy generation, transportation, food, waste, and water. It is anybody’s guess if our hospitals have bothered to implement any of these logical suggestions.

Prevention is less profitable than cure?
Then there’s the conspicuous absence of preventive healthcare in their CSR policies and initiatives. The government had already included ‘promoting healthcare, including preventive healthcare’ in its list of activities qualified to be CSR, so the questions remains as to why these healthcare companies have neglected this critical area.

A conspiracy theorist might well assert that focusing on preventive healthcare means less business for these hospitals. While not Roswellian in terms of its complexity or implication, one cannot help but think that there may be some merit to this claim. After all, prevention is infinitely better than cure, especially when hospital costs are rising by the day and is out of reach for many Indians. Preventive healthcare also ensures healthier people, less prone to diseases and illness and thus less likely to fall into the poverty trap. When large hospitals are intervening in the education space, surely there’s room to promote and build a culture and infrastructure to make people healthier, and not just wiser? Then there’s the lack of attention given to nutrition when India has the dubious distinction of having the largest number of malnourished children, along with high rates of maternal and infant mortality rates – all of which happen to be inextricably linked with preventive healthcare as well. Strange times, indeed.

Preventive healthcare is already known for its many benefits – it improves the health of individuals and the community at large, prevents diseases, has a multiplier effect on the most disadvantaged groups (since treatment costs are mostly unaffordable), focuses on a robust healthcare system and healthy lifestyles, and puts less demands on existing manpower and infrastructure. It also helps in keeping health costs under control since treating illnesses is much more expensive than all the steps needed to prevent them in the first place. It means fewer hospitalisations, shorter lengths of stay in hospitals, and fewer unplanned readmissions after discharge. Equally important is the increased productivity and better mental and emotional health associated with a healthy constitution. The rise of chronic diseases, which is the biggest killer in India, also begs for an efficient preventive healthcare system. Of course, for all of this to happen, an effective public healthcare system is required – one that actually works and places enough emphasis on preventing illnesses rather than treating them. But there’s no recuse for private entities who can do so much more but are caught up in the reactive cycle of dishing out a few free heart surgeries and running mobile clinics. Building toilets is a start but as the results of Swachh Bharat have shown, much more needs to be invested in promoting personal hygiene.

How do these hospitals reconcile their needs to generate revenues with the universal, basic, vital, indispensable need that is health? If current efforts are anything to go by, these enterprises are interested in CSR to the extent that it doesn’t eat up into their balance sheets. Yet, there’s no recuse for private entities who can do so much more but are caught up in the reactive cycle of dishing out a few free heart surgeries and running mobile clinics. Also, delving into education and skills training cannot be faulted but still seems discordant with the workings and expertise of hospitals. It is as if a tech company decided to provide free heart surgeries to children.

Closing thoughtsPrivate healthcare is here to stay and private hospitals are going to drive this, as they have since the past few decades. The issue then is: how do these hospitals reconcile their need to generate revenues with the universal, basic, vital, indispensable need that is health? If current efforts are anything to go by, these enterprises are interested in CSR to the extent that it doesn’t eat into their balance sheets. Customary concessions to some poor customers and free surgeries are laudable to an extent but in the end, the patient is still treated as a customer. News reports like the one where the Delhi government fined five private city hospitals, including Max and Fortis, an amount of Rs 600 crore for not treating poor patients as required by law (despite getting subsidised land) make these kind of efforts seem half-hearted and superficial. Delving into education and skills training cannot be faulted but still seems discordant with the workings and expertise of hospitals. It is as if a tech company decided to provide free heart surgeries to children. It is not a field that they know, understand or excel in.

One hopes that these private hospitals understand that healthcare is a right, not a consumer product like soap or shampoo. Outright profit maximisation, even after receiving freebies from the government while blatantly flouting rules, is inexcusable. CSR is one way in which they can give back to society, in a creative and impactful manner, while fulfilling the requirements mandated by law. Investing in preventive healthcare, nutrition and establishing a culture of environmental sustainability will tremendously help them as well as their customers and society in general. Also, better reporting on CSR as well as adoption of full disclosure on sustainability efforts is definitely the need of the hour. By being reticent, they are doing more harm than good to themselves. CB team was also disappointed at the utter lack of responses to basic CSR-related questions by these large hospitals – their CSR teams preferred to be tight-lipped. Some may say that actions speak louder than words. In this case, we think that there has been little action to warrant many words.